Cardiovascular

CHART NOTE

This 45-year-old woman went in four years ago because of a bad virus infection. At that time, serum cholesterol was 292. She was given niacin in doses of 2000 mg daily, and it dropped only to 262 with HDL of 62. Has a ten-year history of reactive hypoerglycemia, which has improved with diet and supplements. Has a six-month history of insomnia., Ggets “weepy” premenstrually.

ALLERGIES: Codeine.

REVIEW OF SYSTEMS: Has some bloating after meals and excess access flatus. Has urinary frequency, and has extremely cold extremities where she has to wear gloves in the house during the winter.

FAMILY HISTORY: Mother had valvular heart disease, colitis and gallstones. Father had heart attack and kidney stones. Brother has stomach problems. Mother has glutteon sensitivity.

HABITS: Drinks coffee and rare alcohol. Diet is balanced.

ASSESSMENT:
1. Borderline hypercholesterolemia with adequate HDL.
2. Reactive hypoerglycemia.
3. Insomnia.
4. Premenstrual syndrome.
5. Tinnitus related to diet.
6. Cold extremities and dry skin.
7. Seborrheic dermatitis.


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September 10, 2005


Name
Address
Makati City 14344

Re: Pedro Cruz

Dear Sirs:

Mr. Pedro Cruz was admitted at 1700 hours after having had an episode of weakness following GI bleeding approximately three weeks earlier. He was seen by the ambulance people, and was in a rapid heart beat, . tThe exact nature which we do not know, but at any rate Xylocaine was started, and by the time he reached the emergency room, his heart rate was between 75 and 80 with a sinus rhythm. He had excellent ST segments and upright T waves.

When I saw him, his blood pressure was 166/88. Hhis pulse was 75 with a regular sinus rhythm. He had a good carotid pulse bilaterally. His lungs were clear. The heart was not enlarged. There were no murmurs.

He was started on cardiac monitor., Aa chemistry panel was drawn, and the only abnormal finding was a BUN of 22.4.

He was observed closely for any ST or T wave change, and there was none. He had no episode of hypotension. , and T there was no reason to do any cardiac enzyme studies. He did have a follow-up upper GI done because of his bleeding in late June, and this was reported as negative.

There was no further pain,. tThere was no further arrhythmia, and at no time were there any was ST or T wave changes present. I had no reason to do cardiac enzymes, and when I found that his GI track was stable, and that his upper GI did not reveal any new bleeding, and there was no drop in his hemogram, I discharged this patient to be followed by his regular physician.

I hope this information will be of help.

Sincerely,

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INITIAL OFFICE EVALUATION

This 58-year-old female noted a sensation of “shortness of breath” in the high substernal region of the chest. She also describes this as a feeling of “heaviness” or “pressure.” I believe that this sensation is more consistent with angina than true air hunger. The sensation lasteds for about 20 minutes. The patient did not have any radiation of herreduced discomfort, and there were no associated symptoms, other that the shortness of breath as described.

PHYSICAL EXAMINATION:
NECK: The neck is supple without masses. The thyroid gland is not enlarged. The carotid arterial pulsations are equal and full. There are prominent, normal jugular venous pulsations with the patient in the supine position. There is a venous hum on the left, which obliterates easily with minimal pressure on the neck.
CHEST: The chest is symmetric with equal respiratory excursions. There is no thoracic deformity or tenderness. The breasts are normal and free of masses or tenderness.
HEART: There is no visible or palpable precordial activity. The first heart sound is normal in and character and in intensity. The second heart sound is also normal in intensity, but I was unable to appreciate splitting of the second sound. No third or fourth sound was present. The cardiac rhythm is regular, and there is a grade III/VI systolic ejection murmur that is loud at the second left intercostal space. This murmur decreases in intensity markedly with Val Salva maneuver. The murmur does not radiate to the neck.
LUNGS: The lungs are clear to auscultation and percussion, and diaphragmatic motion appears normal.
EXTREMITIES: The extremities are free of cyanosis, clubbing, or peripheral edema. There are bilateral soft femoral bruits. The left femoral artery has a 4+ pulsation, and the right femoral artery has only a 1+ pulsation. Nevertheless, the more distal pulses are normal and symmetric, including the popliteals, dorsalis pedis, posterior tibial pulses.

ELECTROCARDIOGRAM: The ECG reveals normal sinus rhythm. There are T wave inversions that are symmetric in leads V1 through- V3, and lead V4 has a very flat T wave. This pattern is consistent with anterior myocardial ischemia.

ASSESSMENT: This patient has a history which is consistent with angina pectoris. This is associated with an abnormal electrocardiogram that is apparently changed from a previous tracing. The ECG reveals T waves abnormalities consistent with anterior myocardial ischemia. I think that it would be appropriate to perform cardiac catheterization rather than stress testing, since the electrocardiogram has already shown us a signs of ischemic heart disease.

The patient also has a rather loud heart murmur which may be functional, but I have ordered an echo cardiogram to see if this can be further defined.

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HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT: Pain in the chest.

HISTORY OF PRESENT ILLNESS: This is a 40-year-old gentleman referred to this office because of pain in the chest. He states that this pain has been present in the area for some time. The pain is radiating in nature, and the patient is worried about it.

PAST MEDICAL HISTORY: There is no diabetes or history of rheumatic fever in the past. The patient says, “I am really pretty healthy.”

SOCIAL HISTORY: He is a one-pack-a-day cigarette smoker. EtOH intake is negative.

FAMILY HISTORY: His parents both died as a result of strokes. There is no known family history of heart disease.

PHYSICAL EXAMINATION:
NECK: The neck is supple. There are no carotid bruits.
CHEST: Lungs are clear to percussion and auscultation.
HEART: PMI is not displaced. PMI is in the fifth intercostal space. There is no thrill, heaves, gallop, rub or murmur.

LABORATORY DATA: The electrocardiogram is within normal limits.

The patient was subjected to a treadmill stress test. Using the protocol of Ellestad, he reached a maximum pulse rate of 150, which was 93% of his maximum predicted heart rate. There were no abnormalities noted before the exam, there were no abnormalities noted during the exam, nor after the exam. He had a good response to all phases of this testing.

DIAGNOSIS:
1. Chest pains, not on a cardiac basis.
2. Possible musculoligamentous sprain in the costal area.
3. Some risk factors for cardio vascular disease, including heavy cigarette smoking.

DISCUSSION: I find no frank evidence of cardiac problems in this gentleman; however, I believe with some modification of his lifestyle, including the discontinuation from smoking and loosing several pounds of weight, he can enjoy good health for many years. As noted above, his treadmill stress test was interpreted as being completely normal. The patient’s present episode of chest pains are probably only on a musculoskeletal basis and are to be treated with oral analgesics, such as aspirin or perhaps Parafon Forte.


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CHART NOTE

This 19-year-old male presented with an acute onset of left- sided of chest pain. His electrocardiogram done in the office today is entirely within normal limits, and there is no suggestion of pericarditis on the EKG.

The physical exam shows no rub and no pathologic heart sounds.

I would suspect that he has no organic heart disease.

I have recommended that he takes the a rest, a week off from work, and return for follow-up treadmill stress test. If this is normal and he is symptom-free, he may return to work.

IMPRESSION: Chest pain probably musculoskeletal in origin.

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CONSULTATION

It was my pleasure to see this very pleasant 58-year-old white male for evaluation of chest tightness. He has had the symptoms of tightness across the anterior chest which occasionally radiates into both the right and left pectoralis areas and into the shoulders.

The patient does have multiple risk factors for a coronary artery disease. He was told eight years ago that he had elevated blood pressure, and he was advised to start a low-fat and low-salt-diet at that time. He did not go back to his doctor for follow-up blood pressure measurements. He also recalls having an elevated cholesterol at that time.

More rRecently, he had a B/P of 168/96 when he was seen at your office for treadmill exercise test. He smoked two-pack-a-day for some 30 years, but stopped six years ago upon his retirement. A recent cholesterol was 268.

I did review the treadmill exercise test from your office. IWe agreed that the patient had a positive treadmill exercise test with symptoms of typical angina pectoris starting at stage two of the exercise test, and 1mm horizontal ST segment depression in and lead V5 at stage three of the exercise test.

PAST MEDICAL HISTORY: The patient has had probable hypertension and hypercholesterolemia of 8 years’ duration. He was told that he hads some narrowing of the carotid arteries several years ago when he was initially seen by you.

This patient has no previous surgery.

PHYSICAL EXAMINATION:
VITAL SIGNS: B/P, 174/94. Pulse, 76,. rRegular. Rrespirations are normal.
NECK: There is a sSoft bruits over the entire right carotid artery, and a soft bruit at the base of the left carotid artery. There areis no bruits over the subclavian arteriesy.
CHEST: Clear to percussion and auscultation.
CARDIOVASCULAR SYSTEM: The PMI is in the fifth intercostal space at the MCL. The left LV impulse is normal. The rhythm is regular with no premature beats. S1 and S2 are normal. There was is no S3, S4 or gallop. There is a soft grade II/VI systolic ejection murmur heard at the second right and left intercostal space, left stexternal border, and cardiac apex. There is no diastolic murmur.

ASSESSMENT: The patient is a 58-year-old white male who has a stable angina pectoris for 3 years’ duration. His symptoms of are substernal tightness which but ocrecurs with exertion, and which is relieved promptly by rest, this typical of angina pectoris. This is confirmed by your treadmill exercise test, which shows a definite ST segment abnormalitiesy consistent with myocardial ischemia at stage 3 of the exercise test. In addition, the patient has a multiple risk factors including hypertension, hypercholesterolemia and past history of smoking.

I believe the patient should be given a trial of medical therapy for angina pectoris. Anticipate that the patient will have a good response to medical therapy, and that he has a relatively good prognosis. I have started the patient on Cardizem 60mg p.o. tp.i.d which may be increased to a higher dose if he is able to tolerate the medications. This would be helpful for treatment of both in angina pectoris and hypertension. The patient is already taking aspirin three times a week when he plays golf, and this wshould be sufficient. It may be necessary to add other anti-hypertensive medications for better control of his blood pressure. I have asked the patient to return to my office in two weeks to assess the patient’s tolerance to the medication, and to see if he is having adequate antianginal response.

If the patient continues tends to have symptoms of grave exertional angina pectoris on good antianginal medical therapy, then I would be much more concerned that if the patient has significant high-grade stenosis, and he should undergo a coronary angiography study at that time.

FINAL IMPRESSION:
1. Stable angina pectoris.
2. Hypertension.
3. Atherosclerotic peripheral vascular disease.

Again, thank you for asking me to see this patient in for consultation.

end of report

CHART NOTE

The patient is a 67-year-old female who speaks a small amount of English. Patient was seen in my office for her scheduled office treadmill stress test.

However, on examining the patient, and getting the history through an interpreter, we found that the patient has a two-hour chest pressure two days prior to the stress test, and EKG was done in the office which showed new T wave inversions in the inferior anterior leads. The patient has had T wave inversions in the anterior- lateral leads in the past, but the new inferior wall T wave inversions were new. It was felt since patient had two-hour chest pain with new EKG changes, she should not have the a treadmill.

Patient has been on Inderal 10 mg p.o. b.i.d. for a prior her history of hypertension. She denies any shortness of breath, diaphoresis, PND or orthopnea. There is no history of occult bleeding. No history of anemia.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 140/90. Pulse, 60 and regular. Respiratory rate, 20, unlabored. Temperature, afebrile.
HEENT: Was within normal limits.
NECK: Supple, without jugular venous suspension, without carotid bruits, and Nno lympadenopathy is present.
CHEST: Dry rales in both bases, without whizzing or rubs . Ppresent. Bbreath sounds are adequate.
HEART: Heart is regular rhythm without murmur, gallop or rub.
ABDOMEN: Soft, nontender, without organomegaly.
EXTREMITIES: Without No clubbing, cyanosis or edema.

ELECTROCARDIOGRAM: Electrocardiogram shows a regular sinus rhythm with
ST- T waves changes consistent with ischemia versus over subendocardial MI.

IMPRESSIONS:
1. Atherosclerotic Arteriosclerotic coronary artery disease.
2. Unstable angina, and rule out MI.


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